Gabapentins (Neurontin
and Lyrica) are being prescribed
for many types of pain, however, there has been little value in
patients with neuropathy pain from diseases like diabetes and for
chronic low back pain. The gabapentins are fairly successful in
treating neuropathy! In an attempt to reduce the number of opiate
prescriptions, physicians have been prescribing the gabapentins in
combination with opiates (smaller doses—hydrocodone, etc.) with
little success in controlling many types of chronic pain.

Both have been found to depress respiration, and if taken
together in higher doses, can potentially cause death. Studies
recently have reported that
gabapentins are of little value in treating many types of pain. Since these patients have long term pain, they are at high risk
for narcotic abuse, which creates a real challenge for physicians.
Side
effects of
dizziness and sedation can also be multiplied when gabapentins are
taken in combination with opiates.

Discuss this with your doctor if you are being prescribed both
a gabapentin and an opiate and beware of the increased danger. Ref.
NEJM, Apr. 15, 2017; JAMA-Neurology, July 1, 2017

B. Does Zinc shorten a cold?

Since
1968, there have been studies that suggest zinc may help shorten the
length of a cold. Recent studies say it may help but by only 24
hours (as a lozenge or syrup). Zinc sprays can permanently damage
the smell nerves, so it is suggested that patients not use the
spray. Most colds are caused by the rhinovirus, and
it is theorized that a lozenge or syrup may coat the throat
preventing invasion of the virus. Taken at the onset of symptoms may
help slightly. The evidence is not strong. Mayo Clinic

C. New evidence on the occurrence of colorectal cancer in younger
people

Some of you know I have been volunteering for 39 years for the
American Cancer Society (Florida President, National Board of
Directors, Screening Guidelines Committee, Survivorship Committee,
etc.) and we are about to finish our results to be published in
cancer journals on colorectal cancer screening guidelines revision.

I was privileged to be present for a presentation on some
changing trends in colorectal cancer that I can share.

Colorectal cancer is increasing especially in younger people before
age 50 (especially 45-49),
even though the majority of the cancers occur later. The reason is
increasing numbers of colon adenomas (polyps) that are occurring younger in life which become malignant over
about a 10 year period. These polyps seem to be getting more
aggressive in their growth pattern in younger people.

The occurrence of rectal
cancer is increasing in even higher numbers.
The reason is increasing rates of obesity, lack of exercise, and
poor nutrition.Mortality is also rising for younger men 50
and under because of these colorectal cancers.
This age group is not being routinely screened since most current
guidelines recommend routine screening to start at age 50 (unless
there are symptoms or there is a positive family history). Some
national organizations have already starting recommending earlier
screening.

Colorectal cancer is now the number one cause of cancer death in men
50 and under (surpassing lung cancer in the age group 45-49).

I hope to share those guideline revisions soon from the
American Cancer Society.

2-5% of Americans fit the criteria for the diagnosis of the hoarding syndrome. This
may be surprising to some. We all hold on to memorabilia, and
“stuff” we think we might wear or use sometime in the future. But
hoarders keep almost everything cluttering their homes to the max.
It is often a true
health issue as
clutter accumulates mold, rodents, etc. potentially creating
illness. It causes great family discourse.

It was thought to be form of a compulsive disorder in the past,
however, more recently it is felt to be
linked with anxiety, depression, dementia, social phobias, attention
deficit syndrome, and even schizophrenia.

Compulsions may,
however, play a role in hoarding disorder. These people cannot let
go of material goods , not because they rationalize they might use
it, rather they literally cannot part with material objects. It is a
true emotional attachment to “stuff” and would feel an emotional
loss if they were removed. These are not objects most of us would
understand why the person is keeping them. These people do not see
it as a problem, which makes it difficult to treat. Social isolation can also occur to prevent people from ridiculing them.

When parts of the house normally intended for normal use are
used to store magazine, old newspapers, books, cosmetics, clothes,
worn out or unusable equipment, there is a problem. Clutter does not
even come close to what these people’s homes look like. Hoarding can
even include excessive numbers of pets.

70%
report their hoarding started between the ages of 12-21. Some relate the beginning of this syndrome linked to a trauma
at home, forced intercourse, a history of forceful removal of
objects from them, or being abused.

Brain differences

There is a difference in the frontal lobes of these
individual’s brains. This is the part of the brain that processes
rationale, weighing options, and consideration of others. It is
thought that these people use that part of the brain differently.

These
people do not seek help.
Their family may bring them to the doctor’s or there may be fear of
eviction that pushes them, but they come in reluctantly. You may
have seen TV programs on this subject. This is fascinating to
viewers, but not to the families of these people.

Treatment

This is a very difficult disorder to treat and create change in
behavior since most sufferers do not believe they have a problem.
Treating underlying psychological issues may
really be more productive. Ultimately, cognitive therapy to work on understanding how to look at objects and make better
decisions about retaining objects may be of some value. They must
realize that the underlying psychological problem frequently triggers hoarding behavior and the cycle must be broken. They also must
understand the hazards of hoarding (health, fire, vermin, threats to
exiting in an emergency, etc.).

Nagging by family members will not be successful and will even
evoke more underlying anxiety and or depression. Support from family
and friends will assist these patients in reinforcing certain goal
behavior to let go of objects with little value for the immediate
future even if a little at a time.

This common skin disorder plagues men and women ages 30-50
usually fair skinned and blue eyed. Normal teenage acne is called
acne vulgaris.

This is an inflammatory skin disease characterized by facial redness, dilated blood vessels, and
sometimes pimples (acne). It occurs on the face, neck, and back most
often. There can be symptoms of stinging, burning, tightness,
swelling, and tingling. This disease affects people’s quality of
life because of the eruptions, inflammation, and disfigurement.

There are triggers that
can aggravate this disease (heat, stress, hot beverages, spicy
foods, ultraviolent sun rays, alcohol, and smoking). There is
redness, flushing, papules (bumps) and pustules, abnormal blood
vessel formation (telangiectasia), burning, stinging, and dryness of
the skin, which creates peeling and scaling. Thickening of the skin
over the tip of the nose is common (called rhinophyma).

There is a growing body of evidence that this is an immune
disease. The skin reacts to a bacterium called Bacillus olerenius. A protein called cathelcidin, which normally protects the skin
from infection, overreacts and leads to redness and swelling. There
is also an organism called Demodex
folliculorum,
which is a mite that infests the skin in these patients. Whether it
is causal or not is unknown.

There are other diseases to rule out when diagnosing rosacea
(acne vulgaris, lupus, flushing disorders, other forms of
dermatitis).

Having performed this procedure many times, this excessive
tissue can be planed down using
dermabrasion (a
sanding procedure) with amazing results. The before and after photo
(above) is typical of the results that can be obtained. There are
other methods such as laser and loop cautery.

4-ocular-redness, swelling, and small
pustules along the lid margin are the hallmarks of this disease.

An ophthalmologist should evaluate and assist the dermatologist and
must rule out other eyelid diseases.

Treatment

There is no cure, but control of the redness, dilated blood
vessels, flushing, acne, and swelling can be successful with
medication (oral and topical creams) and prevention.

Education about the disease and its triggers, skin care, and
medical management are staples in the management.

Benzoyl
peroxide cleansing of
the areas is a recommended daily therapy for most patients just as
with acne in teenagers.

Treatment should begin with
topical
prescription medications.

The
medications to treat the inflammation are from the tetracycline family (minocycline,
clindamycin),
and
erythromycin.
Oral and topical antibiotics are commonly used in combination. The
newer ones are very expensive, therefore, using less expensive
generic treatments first should be considered, and if they are not
effective, proceed to the more expensive brands.

Another option is metronidazole (Flagyl, Metrogel) in both oral
and topical preparations. Others are
azelaic acid (Finacea) and ivermectin, sodium sulfacetamide, and
permethrin cream.
Oral
isotretenoin (in
the family of the Retin-A) is also effective, but not to be used by
pregnant women because it may cause birth defects. Birth control
methods and frequent pregnancy tests are recommended. All these
options should be discussed with the dermatologist.

For ocular
rosacea,
careful cleansing of the eyelid margin with cotton balls and warm
water twice a day and the use of artificial tears are recommended.
For more severe cases metronidazole or oral doxycycline may be helpful. Also topical cyclosporine drops are very helpful. Off-label use of topical
azithromycin (Azacite)
may be helpful since it is FDA approved for bacterial
conjunctivitis.

The newer topical preparations can cost as much as $500 per
tube.

Flushing may be controlled by beta blockers (used in
hypertension). There is a topical medication called brimonidine (Alphagan) (an alpha adrenergic drug that causes vasoconstriction of
dilated blood vessels). It can also be used as a drop in the eye.
Another is
oxymetazoline gel
mentioned as a common treatment. As a nasal spray, it is called
Afrin, a strong nasal decongestant.

Laser and
light based therapies are commonly used to treat the redness, dilated blood vessels,
and early rhinophyma.

I am a great believer in
estheticians
(specially trained cosmetologists in skin care). All of my cosmetic
surgery patients were encouraged to go regularly to provide maximum
cleansing, clearing of pores, and protection before and after facial
surgeries. Facials by experts are worth every dime. Patients with
skin issues of all kinds will benefit greatly.

I mentioned
dermabrasion is
very effective for rhinophyma to smooth the thick bumpy skin over
the nose.

Prevention

Alcohol, heat, sun exposure, and stress all aggravate acne
rosacea. Artificial tears are valuable but if one has the ocular
type, be sure other diseases of the eye are not present by seeking
consultation with an ophthalmologist. Most patients need to be
treated by dermatology. NEJM,

Pedophilia is a psychiatric disorder and a disorder of sexual
preference that is unusual ( a type of paraphilia). Pedophiles are
defined as at least 16 years of age and be at least 5 years older
than those they are attracted to. Although most commonly diagnosed
in men, women can have the disorder as well. Less than 5% of the
population carries this diagnosis either formally or in secret.

Symptoms
emerge during puberty. Pedophiles often suffer from other psychiatric disorders
(anxiety, depression, and personality disorders). These individuals
are shy, over sensitive, socially withdrawn, and depressed. Thoughts
of suicide are common (46% in one survey).

Relationship with child pornography

Consumption of child pornography correlates better than with child
molestation, as there are non-pedophiles that molest children. Most
of these people have huge collections of photos described as their
prize possessions. These pedophiles are not uncommonly in
underground clubs sharing photos and communications.

There are 2
distinct groups of
people who have sexual interests in children—those who have a
history of sexual abuse against children, and those who have sexual
interests but do not act on their impulses. Co-existing psychiatric
disorders may push those not acting on their impulses into action.

Relationship to child molestation

Not all individuals who molest children are pedophiles. In
fact, Psychology Today states that as many as 20% of American
children have been sexually molested (most commonly by family
members). There are many factors that may come into play including
marital problems, alcohol or drug abuse, stress, the unavailability
of an adult partner, anti-social behavior, or high sex drive.
Pedophilia is less common in incest cases especially in fathers and
step-fathers. One study cited 35% of child molesters are true
pedophiles.

Pedophilia is not a legal term but certainly is the most
stigmatized of all mental disorders.

Structural Brain Differences

Scientists in Germany (Journal of Translational Psychiatry-May,
2017) studied brain imaging in both groups. They found actual structural brain differences in the group who act on their impulses committing criminal acts
of sexual abuse compared to normal individuals who were attracted to
adults. There is less gray matter in the right temporal lobe,
specifically the right
amygdala.
Affected areas are associated with empathy, sexual and social
cueing, and behavioral inhibition. The MRI scans (below) demonstrate
the area in yellow and green.

Other studies suggest less white matter of the brain than
controls.

There appears to be no genetic differences in pedophiles
although there is some familial tendencies. These people have normal
IQs. But it has been suggested that there is a dysfunction at the
cognitive stage of sexual arousal.

Behavioral inhibition therapy implies the ability to not act on impulses due to negative
consequences. If this study can be repeated with similar results, it
may help doctors prevent or treat this horrible disorder.

The
diagnostic criteria for pedophilia include the presence of sexually arousing fantasies, behaviors
or urges that include some kind of sexual activity with a
prepubescent child usually below age 13 for six months or more or
the individual has acted on those urges and feels distress for
having these feelings. A subset of those committing incest may be
included in this diagnosis. True pedophiles are sexually aroused only by pre-pubescent children while there
are
non-exclusive pedophiles can be aroused by adults and children but have a preference for
the children. The diagnosis does not require an actual sexual act
with a child.

Those that perform indecent
exposure to children may or may or not fit the exact criteria for pedophilia, but
certainly are suspect. There are voyeurs also that may be included (peeping Toms). Some studies cite as
many as half of adult males have some of these tendencies or have
acted on them at one time but did not continue.

There is disagreement between the American Psychiatric
Association and other experts. Many want to simplify the criteria to
include anyone who is sexually attracted to pre-pubescent children
whether they act on their urges and fantasies or not.

If a child is the victim of or observer of inappropriate sexual
behavior, they may learn to imitate such behavior and may be
reinforced by these same behaviors in their future.

Treatment

There
is no cure for pedophilia. Treatment centers on helping these
individuals not to act on their urges. Cognitive therapy emphasizes controlling (not curing) the disorder by reducing
behaviors, beliefs, and attitudes that may influence having sexual
activity with a child.

There are medications that can reduce the individual’s sex
drive. Anti-androgens have been used to reduce testosterone levels in males but the
evidence for successfully controlling pedophilic fantasy and
behavior is still in question. Medroxyprogesterone (Depo-Provera) and cyproterone (Androcur) are the two most commonly prescribed. Lupron,
which is also used to chemically castrate prostate cancer patients
is also used with less side effects. All of these meds can cause
weight gain, osteoporosis, breast development and liver damage.
Medical treatment should always be combined with counseling and
appropriate monitoring.

Because there has been observed different levels of serotonin (a brain hormone) in these individuals, somewhat higher doses of SSRIs
(anti-depressants) have shown some success in treating their
underlying depression (Zoloft, Celexa, Prozac, Paxil, and Luvox).
These medications do not resolve the real sexual fantasy and urge
issues. Anti-depressants are successful in decreasing sex drives in
pedophiles as a side effect of SSRIs.

Aversive
conditioning has
been tried with some success. Remember the movie A Clockwork Orange?
Watching video of sexual behaviors associated with a negative
experience such as visualizing a painful experience with the
genitals is an example of this conditioning technique.

Last month, I reported on leukemia (acute and chronic). In addition to leukemia, lymphomas are
cancers that involve the lymph system as well. The lymph system is
intimately involved with the
hematological system,
but is actually part of the circulatory and immune system.

To discuss lymphomas, it is important to give you an idea about
what the lymph system entails. The anatomy
of the system is
below, which includes lymphatic vessels (separate from blood vessels) which traverse the body connecting
all the lymph nodes in a network. These vessels connect into a
conduit called the thoracic duct in left lower neck which dumps the lymph fluid into a blood
vessel (subclavian) for the lymph to be broken down by the liver.

B. Component of the lymph system

The lymph system also includes the bone marrow, tonsils,
spleen, and thymus, as shown below. All these organs can be involved
in lymphoma. I will explain what the spleen is and does immediately following this
report.

C. Functions of the lymph system

The
lymph system essentially filters the body’s tissues, removing
toxins, excessive fluid in the body, poisons, and transports white
blood cells to the blood to fight infections, and produces
lymphocytes (T and B cell lymphocytes which produce antibodies)
primarily in the lymph nodes.

These functions overlap with the hematologic system because the
bone marrow is also part of the lymphatic system, where leukemia
occurs. Leukemia can transform into lymphomas and vice-versa because
the actual cancer cells (lymphocytes) are the same.
Essentially, if the main disease is in the bone marrow, it is
diagnosed as leukemia, and if primarily in the lymph nodes, it is
diagnosed lymphoma.

Lymph nodes can enlarge with infections but also with cancers.
These nodes are present in the neck, chest, abdomen, armpits, and
groin. Every organ has lymph nodes that drain the tissue fluids away
to be discarded.

Lymph nodes are the “policemen” of the body trying to limit
spread of infection and cancers. But cancers can start in the nodes. If these nodes enlarge, doctors need to determine why they
enlarge (infection, metastatic cancer, or lymphoma) with a biopsy.

Lymphomas are cancers of the lymph system, specifically the
lymphocyte, a white blood cell that make antibodies.

D. Classification of lymphoma

Lymphomas account for 5% of all
cancers
according to the NIH (National Institutes of Health) and 55% of all blood cancers. There are dozens of subtypes of lymphomas, however, the two
main categories include Hodgkins and non-Hodgkins lymphoma. Thomas Hodgkin described the disease in 1832. Internationally,
multiple myeloma and myeloproliferative diseases (previously
discussed) are included in blood cancers with leukemia and lymphoma.
90% of
lymphomas are non-Hodgkins type.

E. Signs and symptoms

The primary symptom of lymphoma is swelling
of the lymph nodes
(i.e. see above drawing of the neck nodes).

Systemic
symptoms
include fever, night sweats, and weight loss. Others are fatigue,
malaise, anorexia (loss of appetite), respiratory distress or
shortness of breath, itching, and abdominal discomfort or swelling
(the stomach is the most common intestinal organ to have a lymphoma
although can occur in the colon). Stomach lymphomas occur outside of
the lymph nodes and account for 1-4% of all intestinal cancers.

F. Diagnosis

A
biopsy of a
lymph node is the primary method used to diagnose lymphoma wherever
they are enlarged (neck, chest, abdomen, etc.). Analysis of the
malignant cells is used to categorize the lymphoma using immunotyping, flow cytometry, and other tests. Flow cytometry can provide in-depth knowledge
about the characteristics of a cancer cell. Bone marrow biopsy may be performed to see if the cancer cells are present in the
bone marrow.

Lymphomas occur in the two types of lymphocytes--T-cell and
B-cell. Since the treatments are somewhat different, it is crucial
to know which type it is.

A special test to measure the level of LDH (lactic dehydrogenase) in the cancer cells can help predict
outcome. Genetic analysis for mutations is also a predictor.

G. Staging (I-IV)

Imaging (PET and CT scan) is performed to see the extent of the
disease and is instrumental in staging the disease, as is done in
all cancers (localized, regional, and distant). Staging correlates
with survival.

MRI scan with chest nodes; Chest X-ray with nodes

Intestinal lymphoma

H. Grading of the cancer (low or high grade) of non-Hodgkins Lymphoma

The treatment differs between low and high grade lymphomas.
Follicular lymphoma is the most common low grade (indolent) lymphoma which may not
require treatment if there are no symptoms.

I. Treatment

1-
Non-Hodgkins
Lymphoma-classification

-low
grade/with
symptoms and without symptoms

-high
grade

a) Low grade (indolent) lymphomas (most common is Follicular Lymphoma) grow and spread very slowly
usually with few symptoms. Follicular lymphoma is derived from the B cell lymphocyte, usually diagnosed at 50
years of age or older. Although usually slow growing, they can
become aggressive.

If
asymptomatic
treatment may be delayed because of the side effects of the
treatment.

If
symptomatic,
there is still controversy over frontline therapy—options include
bendamustine (Treanda), *CHOP, or
**CVP with
Rituxin
or Gazyva.
These acronyms are combination drugs (chemo) added to prednisone
plus a biologic agent(Rituxin or Gayzva).

b) High grade lymphomas (the most common is called diffuse B-cell lymphoma) quickly grows in the lymph nodes, spleen, liver, and bone
marrow. They usually present with fever, sweats, and weight loss
(called B symptoms). They can still be controlled but are treated
aggressively with the same chemo agents previously mentioned. These
usually recur within 2 years and will need even more aggressive
chemotherapy and or stem cell transplants.

The FDA just approved the second gene therapy for these lymphomas when standard therapy fails(type
of targeted therapy). The gene is called axicabtagene (Yescarta). This therapy involves extracting T-cells (CAR-T cells--immune
lymphocytes) from the patient’s blood and genetically engineering
them to recognize proteins on the lymphoma B-cells and targets them
for destruction. These cells are then re-infused into the blood
stream for them to do their work (Price of drug minus care-$393,000
and with care probably approaches $1 million. This is being studied
in 22 hospitals (including Moffitt Cancer Institute in Tampa) and is
very promising. These treatments are reserved for chemo failures.
There are consequences (side effects) when manipulation of the
immune system is performed, and that is why it is reserved for a
select group.

Some of the new
anti-tumor necrosis factor agents (TNF-inhibitors) have created an increased risk for lymphoma.
They are used in the treatment of rheumatoid and psoriatic arthritis
and other immunologic diseases such as inflammatory bowel disease (Crohn’s,
ulcerative colitis) such as infliximab (Remicade), adalimumab (Tremfya), and certolizumab (Cimzia). The risk is increased almost three times especially if the
patient has also been treated with thiopurines (Imuran, Purinethol, Lanvis) as well for their inflammatory
disease. Etanercept (Enbrel), another drug used to treat arthritis
also causes an increase risk for lymphoma.

Counteracting inflammation in the body with immunosuppressive agents
comes with a cost of serious side effects in a small percentage of
patients including developing malignancy of the very blood cell
(lymphocyte) that is responsible for creating the immune response in
the body.

2-Hodgkins Lymphoma

If the disease is localized to one area of the body, it can be
treated with radiation therapy. If more extensive (in more than one
area), the *ABVD method can be used. BEACOPP and the Stanford methods are also
used.

There are actually 10 types
of treatment that
can be used depending on the type, severity, relapse, etc. Rather
than get specific with each of the many types of lymphoma, (and
these options are available to most the blood cancers, I will
quickly describe them.

1.Radiation-external, internal—using radioactive materials in wires, seeds,
needles, and catheters, and external total body before stem cell
transplants, 3.
Chemotherapy-oral,
intravenous, into the cerebrospinal fluid, in body cavities, or into
an organ, 4.
Immunotherapy-these
immunomodulators stimulate the body’s own immune system to fight the
cancer (Lenalidomide is used in lymphoma), 5.Targeted therapy-the most common are monoclonal antibodies (Rituximab, Yttrium Y
90 ibritumomab tiuxetan), proteosome inhibitor antibodies, and
kinase inhibitors (idelasilsib) are all used in non-Hodgkins type,
6.Plasmapherisis—remove the plasma and then specifically remove unneeded plasma
protein antibodies, 7.Surgery-to remove tumors especially in indolent types, and splenectomy,
8. Stem cell transplant, 9. Antibiotics-for infections, and 10. Watchful waiting in indolent asymptomatic lymphomas.

First time vs recurrent lymphoma

This
is a difficult discussion and has many factors to consider,
including what was used the first time. Stem cell transplants and
biologic therapies (Retuxin, Gayzva) are part of the discussion.
Also clinical trials should be considered.

Under investigation

Biologic therapy is a type of therapy that also attacks
specific cells similar to immunotherapy. Vaccines are
an example. These are being tested along with many new types of
therapy in clinical trials. This could be an option when other
therapies are ineffective.

Late effects of treatment

The
chemotherapy and other forms of lymphoma treatment carry a price for
multiple drug treatment. These chemo agents may cause heart
problems, infertility, loss of bone density, neuropathy, and
secondary cancers, but also bankruptcy (because of the enormous
cost), prolonged depression, permanent pain, etc. I bring these last
few items up because of the outrageous prices Big Pharma is getting
away with. I recently wrote a report on this subject (September,
2017), but this is the latest:

Novartis pharmaceuticals just received FDA approval a new drug
for treatment of leukemia and some lymphomas. The price of the drug
alone is $475,000. They rationalize it is cheaper than the cost of a
stem cell transplant. Wow!!

5 year survival rates and percent of the total number of cases by stage (note
the percent who present with distant disease)

I—localized—26% of cases; 5 yr survival 82.3%

II—Regional—19% of cases; 5 year survival 78.3%

III--Distant—47% of cases; 5 year survival 62.7%

IV—Unknown—8% of cases; 5 year survival 68.6%

Summary

Lymphomas are not curable but very controllable. Almost half of the
patients already have distant disease when first diagnosed although
still do very well for prolonged periods of time. There will be
relapses, usually within 2 years, therefore, treatment does not have
to always be ongoing.

There are maintenance drugs for some lymphomas. Watchful
waiting is a reality for very slow growing lymphomas (indolent) with
no symptoms. This may seem odd to some, but considering the
significant side effects and the fact that treating earlier does not
change the course of the disease, it is a real option.

I have talked about the spleen many times and have not explained
what this organ is and what its functions are.

Anatomy and function

The spleen is an organ that sits up under the left ribs in the
uppermost abdomen opposite from the liver which occupies the right
upper abdomen. It is the size of a small fist (~4 inches long).

It is part of the hematological system/immune system that
filters blood, gets rid of old red blood cells, can store blood in
certain circumstances and even make blood cells (lymphocytes and red
cells), especially when the bone marrow is not doing its job. It can
also fight infections because the spleen contains a cell called a
phagocyte
which
can engulf bacteria and destroy them. It also stores red cells and
platelets (as much as 40% of platelets).

The spleen does not get much attention until it becomes
enlarged and can rupture creating a true emergency (hemorrhage)
requiring surgical removal since it can’t be repaired. It can
rupture in a fall, a car accident, or from disease.

Enlargement

The spleen can enlarge from infectious mononucleosis,
toxoplasmosis (parasitic disease), and endocarditis (infection in
the heart), inflammatory diseases (rheumatoid arthritis, sarcoidosis),
diseases of liver (pressure backs up from the liver in the
veins—i.e. cirrhosis, cancers especially leukemia and lymphoma, and
from trauma.

When the spleen becomes enlarged it can aggressively destroy
blood cells necessitating its surgical removal. Therefore, in recent
reports the spleen was discussed in the disorders of the red cells,
white cells, and platelets.

The physician should not be able to feel this organ in the
upper abdomen. If he or she can, it is considered enlarged and
should alert the doctor for a workup looking for a cause.

Can you live without a spleen?

Yes, but the patient can be prone to infections from strept
pneumonia (pneumococcal infections), Neisseria meningitides
(meningitis), and Haemophilus influenza.

It is critical for patients who lose their spleen to stay up to
date on the flu vaccine, and get the pneumococcal vaccine (pneumonia
shot) (Prevnar 13). If the pneumonia shot is received before age 65,
a booster is recommended in 5 years, however, if over 65, a booster
is not necessary, according to the CDC.

II. How gum disease is one of the leading causes of inflammation
and how it influences systemic disease

I. Inflammation and Disease

I have mentioned many times that the mouth, especially gum
disease, contributes to chronic inflammation in the body and can
aggravate many diseases. The mouth is a clear source for bacteria to
enter the blood stream. Bacteria can be found in the blood stream
after the teeth are brushed. Anytime there is a vulnerable area in
the body, gum disease and its bacteria can attach to these areas,
especially artificial or damaged organs such as a heart valve, a
replaced joint, an artery with plaque in it, etc. causing severe
consequences.

Pro-inflammatory cytokines

It is also known that inflammation in one area of the body can
have deleterious effects on the inflammatory process in another part
of the body. There are chemicals (cytokines,
C-reactive protein, etc.) that are well known in the inflammatory process that
create disease for vulnerable areas of the body, including organs
such as the pancreas, and has long thought to be involved in
contributing to type 2 diabetes. It is well known gum disease secretes these pro-inflammatory cytokines.

There are tests that when elevated indicate non-specific
inflammation—one is called ESR—erythrocyte
sedimentation rate and another is the C-reactive protein test. However, chronic inflammation can be present without these
tests being elevated. An elevated test must be correlated with
clinical findings to focus in on the site of inflammation. It should
be noted that with gum disease and certain illnesses, there is an
association not a causation with periodontitis and certain
illnesses.

II. Periodontal (gum) disease

A. Statistics

According the CDC, 47% of men and women over 30 years of age,
and 70% over 65 have some degree of periodontal disease.
It is no surprise, since only 64% of American adults see a dentist
regularly. Without dental cleanings and professional examinations
(along with twice daily brushing and flossing)the risk for dental
and gum disease is very high.

A
recent study of
postmenopausal women with periodontal disease cited a 14% increased
risk of certain cancers.
These are observational studies but still legitimate. It is still
unclear whether periodontal disease causes cancer, however, the same
bacteria have been found in esophageal cancers. These women have an
increase risk of cancers of the lung, esophagus, gall bladder,
breast, oral cavity, and melanoma of the skin. A slight increase
occurred with stomach cancer. Smoking history although often
associated with periodontal disease and cancers still showed
increased risks in non-smokers with periodontal disease.

C. What causes gum disease?

Gum disease begins because people are
not following their dentist’s guidelines for dental disease
prevention. Without daily brushing and flossing, deposits of
bacteria begin to accumulate on the teeth especially between the
teeth and gum line (plaque).
As this process progresses, inflammation begins in the gums leading
to gingivitis,
periodontitis
and ultimately loss of teeth.

D. Plaque and Tartar--definition

Bacteria fill the mouth of all people and form a sticky substance
with mucus and other particles to create what is called plaque.
Plaque that is not removed routinely will harden causing tartar. Once tartar is present, it may take a dental hygeinist to
remove it. That is one of the main functions of a dental cleaning.
Flossing (and water irrigations) can control plaque if routinely
removed. Electric
toothbrushes are
more effective in removing plaque than regular brushes.

Irrigator

Interdental cleaning instruments

E. Gingivitis

When plaque and tartar persist, it
causes inflammation of the gums, which is called gingivitis.
This is also a reversible process with proper dental care. Redness
and easy bleeding of the gums are signs of gingivitis. It is time to
see the dentist. No toothpaste (including parodontax) is going to
substitute for seeing a dentist if gingivitis is present.

F. Periodontitis

If gingivitis is not treated, the
disease progresses to periodontitis,
which means extended inflammation deep into the gums around the
teeth. As the gum disease progresses, the gums pull away from the
tooth creating pockets that become infected and go below the gum
line. The body’s natural defenses and bacterial toxins try to
dissolve these plaques and tartar, but in doing so, start breaking
down the bone and connective tissue which holds the tooth tightly in
place. When that occurs, the ultimate result is tooth loss.

G. There are risk factors that accelerate gum disease:

1. Smoking and chewing tobacco(this includes smoking pot
regularly which is very drying to the mouth)

2. Hormonal changesin girls and women can make the
gums more sensitive and more prone to gum disease.

5. Patients with cancertreated with chemotherapy and
radiation especially head and neck cancer patients who have
treatments of the mouth and throat (includes the jaws, teeth and
gums).

6. Dry Mouth syndrome secondary to
medications

There are hundreds of prescription and OTC medications that cause
dryness of the mouth. (Expanded information in the January 2018
report)

7. Geneticpredisposition to gum disease

H. Progression of periodontal disease

Recession of the gums leads to exposure of the deeper portions of
the teeth as shown in the X-rays on the next page. As the gums
recede, pockets form leading to bone loss around the teeth, which
leads to loosening of the tooth and eventually tooth loss.

Note the recession of the gums exposing more of the teeth in the
two images below.

Dental x-rays

Normal
X-ray

(Good bone between

teeth--arrow)

Bone loss between the teeth

J. Treating Gum disease

The goal of treatment is to control
infection with comprehensive professional dental care (including
deep cleanings) combined with daily home dental care. Home care
should include using an irrigator to clean the pockets out that
flossing cannot reach.

If a general dentist deems it necessary, referral to a
periodontist should be entertained especially if treatment below the
gum line gets fairly deep. If these gum pockets get too deep--5-10
mm (by measuring with a small dental probe), the tooth may need to
be removed. Below is a dental probe checking for pockets.

Dental probe in a pocket

Probe in pocket seen below

Note tartar deposits at base of tooth

K. Scaling and root planing to remove plaque and tartar

The instruments are used to clean the tooth plaque and tartar
even down below the gum line in these pockets.

L. The Dentist/Dental Hygienist team-their vital role

I cannot overemphasize the value of a
dental hygienist and dentist to see people regularly. Patients tend
to skip seeing their dentists when the budget gets tight. However,
prevention of dental disease is a crucial healthcare concern and
should be considered as vital as seeing the primary care physicians
routinely. The dentist’s examination and X-rays can find early
hidden disease and handled more easily and less expensive than
waiting til there is a full blown issue is discovered. Prevention is
the hallmark of dentistry as it is in medicine.

A special thanks from my personal dentist, Dr. Ray Gyselinck, in Dillard, Georgia, who
reviewed this report and made important contributions.

Next month, I will report on the dry mouth syndrome and its
serious effect on dental and gum disease,
plus an extensive self help section.

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